Siccardi M, et al., J Reprod Med Gynecol Obstet 2020, 5: 035 DOI: 10.24966/RMGO-2574/100035 HSOA Journal of Reproductive Medicine, Gynaecology & Obstetrics Research Article Conclusion: The dynamic postural method of external pelvimetry, Evaluating two Postural Change suitably adapted to clinical needs, demonstrates that it is possible Methods for the Positional to evaluate the range of pelvic movement with the shifting position. Dynamic Measurement of the Introduction Dystocia is still one of the major causes of complicated deliv- Diameters of the Michaelis ery and maternal and neonatal morbidity [1,2]. Among the causes of dystocia, the most difficult to predict and prevent is the so-called Sacral Rhomboid Area “contracted pelvis” which does not allow the commitment of the part Marco Siccardi1,3*, Cristina Valle1, Fiorenza Di Matteo1 and presented within the pelvic excavation or prevents its progression Valentina Angius2 with possibly disastrous consequences for the woman and the fetus. A screening or diagnostic method addressed to the contracted pelvis 1 Department of Obstetrics and Gynecology, San Paolo Hospital, Savona, would improve the quality of childbirth for mothers and babies. In Italy obstetrics manuals and osteopathic learning courses [3-5], it is sug- 2Department of Obstetrics, San Paolo Hospital, Savona, Italy gested to evaluate the shape and the postural changes of the area of 3Primal Osteopathy Institute, Savona, Italy the sacral rhombus of Michaelis from the upright to the squat posi- tion: it would relate the space in the pelvis for a safe childbirth. They generically stated that, by changing the posture, the shape and size of the sacral rhombus change when the pelvis is free to expand, and the Abstract sacral area widens progressively from the up right to the squat posi- Introduction: The diagnosis of “contracted pelvis” is still a challenge tion. Despite such affirmations, the postures were not well described in the obstetric field. The early diagnosis could avoid neonatal and and standardized, a device to quantify and objectify the changes in the maternal complications resulting from suffering caused by prolonged measures of the diameters was not developed, there do not normality labour and operative delivery, especially in countries with low so- reference curves, no correlation with the obstetric outcomes was sta- cio-sanitary content. Radiological pelvimetry has shown that the en- tistically calculated. dopelvic space is modified according to the posture that the subject assumes: between the prone position, the “four supports” and in the The rationale of the present study comes from researches per- squat, changes of internal diameters have been highlighted. Our formed by MR and optoelectronic devices in pregnant and non-preg- study would like to investigate the possibility of highlighting the same nant women [6-9]. They showed an increase in transverse internal type of modifications through external pelvimetry. diameters of the pelvis and a variation in the lumbosacral angle with Methods: Thirty healthy non-pregnant women were recruited. The the degree of flexion of the hip joints. Our hypothesis starts from transverse and longitudinal diameters of the Michaelis area were the evidence that the pelvis is a whole: changing the position in the measured with two different dynamic methods to change the 3 pos- tures in which to perform the measurements: upright position, 90° three-dimensional space of one of the iliac points applies to the move- ment of all the other points (Figure 1) [10]. If significant variations position of the hip, squat position. The measurements were taken of the internal pelvic diameters have been demonstrated on MR, the with a suitable patented instrument. same variations should also be found for the external pelvic diameters Results: With both methods the diameters of the sacral area un- dergo an increase in measurements, suggesting a corresponding [10]. The human hand has fantastic proprioceptive properties and can increase in the internal pelvic diameters with the passage from the manipulate small objects with great precision [11], manual medicine standing station to the 90° position and the squat position. operators are trained to evaluate very small, almost non-quantifiable ranges of motion, while the expected range of motion for this study *Corresponding author: Marco Siccardi, Department of Obstetrics and Gy- is around 5mm [6,12]. The few studies present in the literature have necology, San Paolo Hospital, Savona, Italy, Tel: +39 0198386311; E-mail: [email protected] used two different postural procedures that have been used in the present study [6-8]. The present study aims to verify the precision, Citation: Siccardi M, Valle C, Di Matteo F, Angius V (2020) Evaluating two Pos- reliability and concordance of the quantitative measurement of the tural Change Methods for the Positional Dynamic Measurement of the Diameters of the Michaelis Sacral Rhomboid Area. J Reprod Med Gynecol Obstet 5: 035. transverse and longitudinal diameters of the Michaelis area in the up- right position, in the position with the hip joints at 90° and in the Received: December 25, 2019; Accepted: January 14, 2020; Published: January 21, 2020 squat position; to test the correspondence of the measurements in the different positions. This is a preliminary study to check and choose Copyright: © 2020 Siccardi M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits the procedure for changing the positions, addressed to the possible unrestricted use, distribution, and reproduction in any medium, provided the use of the measurement method in women in the late third trimester original author and source are credited. of pregnancy. Citation: Siccardi M, Valle C, Di Matteo F, Angius V (2020) Evaluating two Postural Change Methods for the Positional Dynamic Measurement of the Diameters of the Michaelis Sacral Rhomboid Area. J Reprod Med Gynecol Obstet 5: 035. • Page 2 of 7 • First postural method (“standing positions”, Sp) (Figure 3A-3C). Sp1: patients start on the standing position with feet parallel to the width of the hips. Extended lower limbs. Pelvis, spine and head in the neutral position as for the standard measurement of body height. Arms along the sides. Sp2: to bring the hip joints “at 90°”, the subjects perform flexion of the entire spine and pelvis around the hips, resting the arms and torso on the examination table placed at a suitable dis- tance and maintaining the knees in full extension. Sp3: bending the lower limbs, keeping the heels resting on the ground, they move to the “squat” position. The arms and hands resting on the examination table can help maintain balance. Second postural method (“kneeling positions”, Kp) (Figure 3D- 3F). Kp1 (upright kneeling position): the upright position as in the previous method, with the difference that the support on the ground occurs through the knees, with the ground tibia flexed to 90° on the femur. Kp2: flexion of the hip joints “at 90°” using the position on the “four supports” (“all four”): the patient brings the weight forward resting her hands on the. Kp3: finally, bringing the ischial tuberosities Figure 1: A and B osseous model of the pelvis. C and D reconstructed model of the pel- vis. Changes of the width in internal diameter (pelvic inlet, red arrow) through the iliac towards the heels and the torso towards the supporting surface, sub- anteriorly rotated (B and D) correspond changes in external pelvic diameter (transverse jects pass to the position of “squat” on the knees (“kneeling squat”). diameter of the Michaelis sacral rhomboid area, green arrows). Methods Thirty healthy non-pregnant women were recruited, and the study protocol and its aims were explained: all of them expressed their in- formed consent. Only nulliparous subjects who did not report abdom- inal, pelvic or vertebral surgical interventions, did not suffer from lumbopelvic pains and did not have abdominal-pelvic diseases at the clinical evaluation were accepted. The study was conducted in con- formity to the Helsinki declaration. The study protocol was defined by the first author who refers to the Obstetrics Department of “San Paolo” Hospital of Savona, Italy (board approval number: 119933- 2019). The number of subjects recruited exceeds the minimum sug- Figure 3: First postural method: a, b, c. Second postural method: d, e, f. gested of twelve/fifteen subjects for the evaluation trials in biome- A: sp1; B: sp2; C: sp3; D: kp1; E: kp2; F: kp3 chanical studies concerning the significant effect on statistical power [13]. Two different ways of obtaining the three different positions were compared, using a suitable CE patented measuring instrument: All thirty subjects performed both postural protocols, while the the “Bone-Meter Kit” - BMK - Metrica SpA, Milano, Italy (Figure 2), operator took measurements of the two diameters of the pelvic sacral which has an accuracy of 0.2mm and a resolution of 0.1mm [14]. area in all six positions. Procedure: (0) the operator shows both pro- tocols “standing” and “kneeling”; (1 and 2) the subject performs the two protocols while the operator keeps the contact of the fingers on the posterior superior ischial spines to be able to correct movements and positions; (3 and 4) the subject performs the “standing” proto- col twice, while the operator first measures the transverse diameter and then the longitudinal diameter of the diamond of Michaelis in the three positions; (5 and 6) the subject then executes the “kneeling” protocol twice while the operator measures the transverse and lon- gitudinal diameters of the Michaelis diamond in the three positions. In the end, the subjects were asked to choose one of the two postural procedures, based on simplicity and ease of execution. The measurements of the study refer to the transverse and longi- tudinal diameters of the Michaelis rhombus [14-16] (Figure 4). The transverse diameter is subtended by the two Posterior Superior Is- chial Spines (PSIS).